The document discusses the treatment of severe asthma exacerbations in the emergency department. It outlines several mainstay treatments including beta-2 agonists, ipratropium, and steroids. For patients not responding to initial treatments, it recommends considering magnesium, intravenous epinephrine, non-invasive positive pressure ventilation, or intubation. The document provides guidance on appropriate ventilator settings and treatments for potential complications of intubation like barotrauma. It concludes by listing additional resources on managing the crashing asthmatic patient.

1. Sometimes What Wheezes
is Asthma
Melissa Beckmann
10Jul 2013

2. What We Will Talk About
 Treatment of Severe Asthma in ED
 What works and What Does Not
 Treatment of the Crashing Asthmatic
What We Won‟t Talk About
• Treatment of the Mild-Moderate Asthmatic

3. Today‟s Trivia
OR
OR

4. Asthma PSA

6. Risk Factors for Death in Asthma
 Previous severe exacerbation (ICU/intubation)
 2 or more hospitalizations for asthma in 1 year
 3 or more ED for asthma in 1 year
 Hospitalization/ED visit for asthma in last month
 Using >2 MDI short acting β2 agonists in last month
 Current or recent use steroids

7. Mainstays of Asthma
Treatment

8. β2-agonists
Camargo CA et al. Continuous versus intermittent beta-agonists
for acute asthma. Cochrane Database Syst Rev. 2003;(4):C
 N = 461 Adults and pediatric
 Participants got either:
 10-30mg albuterol over 2-4 hours OR q20 minute nebulizers,
q30 minute nebulizers, or q1 hour nebulizers.
 90% saw no benefit
 10% decreased hospital admission rate
CONTINUOUS IS BETTER

9. Ipratropium
The nnt looked at 6 meta-analyses from 1999-2006
 Ipratroprium added to beta 2 agonist therapy
 N = 1500
 Decrease in hospital admission by 9%
 NNT = 11.5 (11.5 treated to prevent 1 admission)
 3 nebules is the max for 6 hours
IPRATROPIUM GOOD

10. Steroids
Rowe BH et al. Early emergency department treatment of acute
asthma with systemic corticosteroids. Cochrane Database Syst
Rev. 2001;(1):CD002178
 12 studies- Steroids given within 1 hour. Both pediatric (PO)
and adult (IV/IM). Followed up between 3 and 21 days.
 N = 863
 NNT = 5
 12.5% were helped by preventing hospital admission
 10.0% were helped by preventing asthma relapse
 9.1% were helped by preventing a later hospital admission
GIVE STEROIDS

11. Mainstays in Treatment
 β2-agonists
 Hit „em hard, hit „em long
 Anticholinergics
 Especially effective in children
 3 nebules max for 6 hours
 Steroids
 Give early but will take time to work

12. Trivia
This resident competed in an Ironman and has the tattoo
to prove it. Additionally, she has this license plate:

13. ANNA

14. IT‟S NOT WORKING,
NOW WHAT?!?!?!

15. Magnesium
BH et al. Magnesium sulfate for treating exacerbations of acute
asthma in the emergency department. Cochrane Database Syst Rev.
2000;(2):CD001490.
 N = 665 Both pediatric and adult
 Most studies gave as bolus (1.2-2gm/20 min, or peds 25-
100mg/kg). 6/7 gave within 1st hour
 67% no benefit
 33.3% severe asthmatics prevented hospital admission
 For severe NNT =2
 100% non-severe asthmatics were neither harmed/helped
GIVE MAGNESIUM EARLY

16. IV Epinephrine
 Potent, Reduces Airway Resistance
 α effect leads to vasoconstriction
 1:10000 (crash cart epi)
 0.25cc is a 25mcg push if crashing
 2.5cc in 250mL NS (1mcg/mL sol‟n) run over 25 min
(10mcg/min)

17. Non-invasive Positive Pressure
Ventilation
Non-invasive positive pressure ventilation for treatment of respiratory
failure due to severe acute exacerbations of asthmaLim WJ, Mohammed
Akram R, Carson KV, Mysore S, Labiszewski NA, Wedzicha JA, Rowe BH,
Smith BJ. December 12, 2012
 6 trials, N =206
 Compared to usual medical care alone, NPPV reduced hospitalizations,
increased the number of patients discharged from the emergency
department, and improved respiratory rate and lung function
measurements. The application of NPPV in patients with asthma, despite
some promising preliminary results, still remains controversial. Further
studies are needed to determine the role of NPPV in the management of
severe acute asthma and especially in status asthmaticus.
 Increases FRC, Decreases WOB
USE NPPV

18. Trivia
This resident is a former cheerleader, went to the best
medical school in the country, hates public speaking, and
is a bad ass rock climber.

19. ANNE

20. IT‟S STILL NOT WORKING,
NOW WHAT?!?!?!

21. Intubation
 18% mortality if intubated. Probably lower now that we
have better vent settings
 Death-asphyxia, tension ptx, reduced venous return
 Diaphoretic/Decreased responsiveness

22. Intubate
 Lidocaine (1.5mg/kg)
 IV or inhaled
 Reduces airway responsiveness
 Ketamine (1-1.5mg/kg)
 Weak bronchodilator
 Can consider (0.5mg/kg) in agitated patient
 Succ (1.5mg/kg) or Roc (1mg/kg)
 Recommend giving ketamine/lido while sitting up and then
laying down and pushing paralytics. Also recommend most
experienced person place ET tube
 Have the cric ready

23. Ventilator Settings
 Barotrauma, Breathstaking, DEATH
 Initial RR 6-8 breaths/min (DO NOT HYPERVENTILATE)
 Small TV 5-7cc/kg
 Small PEEP (0 or 2)
 Large I:E ratio (1:5 up to 1:8)
 Don‟t worry about CO2/acidosis
 Keep plateau pressure under 30

24. Trivia
This resident is president of AAEM/RSA, is the youngest 2nd
year, is a country line dancing fiend, loves to shoot guns,
has an amazing ability to NEVER be hungover.

25. MEG

26. CODE BLUE CRIT 5

27. Barotrauma, Breathstacking,
Decreased Venous Return, DEATH
 Fluid bolus 1-2L
 d/c ET tube
 If O2 sat is >88% manually press on chest for about 60
sec
 Bilateral needle decompressions and chest tubes. DO
NOT WAIT FOR X-RAY

28. Summary
 Β2 agonists, ipratropium, steroids
 Magnesium, IV epinephrine, NIPPV
 Intubate using lidocaine, ketamine, paralytic
 Low PEEP, low TV, long I:E ration, low RR, watch plateau
pressure
 If pt arrests think barotrauma: d/c ET tube, b/l
needles/CT

29. Resources
 The NNT
 Cochrane Review
 EM:RAP “The Crashing Asthmatic” April 2007
 FOAM:
http://emergencymedicineireland.com/2013/05/the-
crashing-asthmatic/

30. Last Trivia
This resident is the most socially awkward of the second
years, often doesn‟t know what to do with her hands, also
went to the best medical school in the country, and is
thankful to finally made it through an intern year!

31. Melissa

32. Melissa

33. G-Induced Loss of Consciousness
aka GLOC

34. How F-16 pilots die in the aircraft
 Human Error
 GLOC, Hypoxia, Spatial D
 Jet Error
 KIA

36. GLOC Graph

37. Prevention
 Physical Fitness
 Overall Health
 G-Suit
 Anti-G Strain Maneuver

38. G-suit

39. What GLOC looks like inside